OB Senior Role 2015
Faculty Administrator:
Joe Breuner, MD, First Hill
Pat Gemperline, MD, Cherry Hill
OB Chief Residents: (page or email the group with any questions)
Claire Frost- First Hill
Marissa Kummerling and Robie Sterling- Cherry Hill
R2s from both Cherry Hill (after Block 1) and First Hill will be present for teaching and direct critical skills observation of each R1 during their first two shifts.
Goal: Provide labor deck support and supervision to new R1s as they begin their obstetrics experience. Develop R2 teaching and supervisory skill. Teach critical skills to R1s through direct, hands-on teaching and one-on-one observation.
Objectives:
1.) Demonstrate competency in supporting and training R1s in admitting and managing labor deck responsibilities.
2.) Successfully teach assigned topic and test R1 for competency in assigned area. This can be done during the direct observation shifts or on the teaching half days.
3.) Ensure that every intern is aware they can call/page a senior resident day or night from the Red of Green team with questions if they arise during their shift. The OB chiefs and FMS seniors are happy to help.
4) Cover Green Team OB deliveries while on L+D shifts.
5) Cover Group Health Purple team deliveries while on Group Health call days. (see separate Purple team document)
6) Supervise R1s in getting postpartum moms seen (and newborns for Country Doctor/ICHS).
Day 1 of Every Block with New Interns:
If you are the OB R2 on as Day Buddy during the first day of the block, please ensure the following with the whole group of new interns (this can be brief since it should be reviewed during the first two shifts as well):
- Review of EPIC for OB: "dot" phrase (make sure everyone has them and knows which ones to use), doc flowsheet (basic where information is located, pit dose, last cervical exam, etc), and order sets.
- Orientation to Triage: how triage works, including where supplies are, run through of how common complaints are addressed in triage), and direct them to OB Triage cheat sheet on the website
- Discuss time management: what should happen first, how quickly to see patient/return pages, priority of activities, etc.
- Postpartum care and Antepartum expectations.
*** All R1s not in clinic and on their first block of OB would be expected to attend. They won't have any antepartum patients to see, so this can be done before perinatology rounds or after.
*** If you are not able to do this on day one, please coordinate with the OB R2s to ensure that it happens within the first 3 days of the block.
Teaching Topics to be covered during direct observation days (Day/Night Buddy):
1. NSVD/IUPC/FSE/AROM- skills that at best should be observed for competency but can be performed on models during the second exclusive teaching day.
2. Knots/Tools/Episiotomy repair- direct observation or on the model
3. FHR tracing interpretation- ensure that R1s complete gnosis training. Liz Stahl has log on info.
4. U/S review/PROM evaluation- direct observation or during the review teaching day.
Duties and Timing:
Mon.-Fri. 7:00am - 3:00pm [when not in clinic/ultrasound]
During remaining L+D teaching shifts, direct R1 on call to most productive experiences. Work doing triage evaluations and labor management so that interns don't miss deliveries. Do teaching panel and green team deliveries and supervise the R1 doing these deliveries. It is expected that we will double count these, it's part of our teaching culture.
When labor and delivery is slow, please help interns get their OB competencies completed.
Also please teach informally on topics that come up during antepartum rounds, goal will be to help R1 comprehension of antepartum care topics.
Basic Orientation:
Topics that should be covered to orient new R1s to L&D, triage, and the OB R1 role:
Introduction to nursing desk and the white board, putting your name on the board, meeting charge nurse, secretary, etc.
Tour of L&D and triage – orient R1 to an empty delivery room and triage room
Delivery room: sterile gloves, extra gowns, booties, what is on the delivery tray/table, how to place blue drape/bag appropriately during delivery, how to clean up after delivery, where red and white trash cans are, etc.
Triage room: light, stool, US, sterile spec supplies, how to break down a bed, microscope
Show where and how to update sign-out sheet on computer on 5SW and L&D tracker
Orient to morning rounds/postpartum rounds/antepartum rounds how the day flows
Make sure residents have the appropriate dot phrases and order sets
Review note writing
Review order entry
Competencies:
All interns will be given a competencies card that they are responsible for getting signed as the competencies are completed. Once all of the competencies have been achieved, the intern will then give their competency cards to Joe Breuner or Pat Gemperline.
Deliveries:
Supervising R2s can and should be present for all vaginal deliveries. This will be discussed with the attendings but given this is the first year, please be patient with nurses and attendings as you explain your supervising role. R2s can count deliveries in New Innovations by marking them as performed or supervised. Only one person can mark each delivery as being in the supervising role. It's OK for two residents to report performing the delivery.
Other Teaching Requirements:
R1s, OB Fellows, Pat and Joe (Wednesdays only) will continue to do teaching from 7:30-8am.
- Please help ensure that everyone knows to sign up for the teaching topics when you are on as the Teaching person.
Teaching schedule 7:30 every morning 5SW Conf Room:
Mondays OB fellow
Tuesdays OB Senior First Hill
Wednesdays Pat and Joe
Thursdays Conferences
Fridays OB R1s.
Sign up for topics on calendar. Topics are assigned by the day.
R1 OB Competencies
__R2 Initials__
□ Cervical Exams: _____________
□ NSVD: _____________
□ FSE: _____________
□ IUPC: _____________
□ Surgical Knots: ______________
□ Lac/Episiotomy Repair: ________
□ FHT Interpretation/passed Gnosis module: ___________
□ US Review (AFI, cephalic presentation): ______________
□ PROM Management: __________
OB R1 Competency Task List:
For each task, R1 will state 3 indications, 1 contraindication, demonstrate competence, and model narrating procedure to patient while performing. Ok to repeat task until competence demonstrated.
Competent Not Competent
Cervix Check
Indications (fetal distress, rupture _________ _______
Of membranes, urge to push,
Bleeding with US=no previa)
Contraindications: known placenta __________ ________
previa, vasa previa, unknown placental
location)
Demonstrates (competent within 30% ________ ________
Effacement and 2 cm of dil)
Narrates to patient _________ _________
Fetal scalp electrode placement (can use BSQ form also in teaching folder)
Indications (poor quality external _________ _________
tracing, concerning category
II strip, prolonged deceleration)
Contraindications: active herpes lesions, ________ _________
High viral load HIV or hepatitis,
Non-vertex presentation, placenta
Previa or vasa previa
Demonstrates ______ _________
Narrates to Patient _______ __________
Intrauterine Pressure Catheter placement
Indications (pitocin augmentation, ______ ______
Poor labor progress or arrest,
amnio-Infusion, Trial of labor
after Cesarean (TOLAC)
Contraindications uterine bleeding _______ ________
Undetermined origin,
Chorioamnionitis a relative CI
Demonstrate _______ ______
Narrative to patient _______ _______
AROM:
Indications: necessity for fetal monitoring --------- -----------
when membrane intact, question mec, speeding up
slowed labor.
Contraindications: palpable cord, unstable lie, --------- ----------
Presentation unknown, not fully engaged
EPISIOTOMY REPAIR: Score sheet to use for practice with OB R1
**Also review the procedures consult on the First Hill curriculum page to watch videos of episiotomy repairs!!
1 Evaluation of injury
A. Does the examinee perform a rectal examination? Yes No
B. Does the examinee appropriately identify the degree of injury? Yes No
2. Anesthesia considerations
A. The examinee determines the degree of patient anesthesia by testing Yes No
The examinee should then be prompted by the examiner that the patient does not have adequate
anesthesia.
B. The examinee infiltrates the perineum in an appropriate fashion with appropriate
anesthetic agents Yes No
3. Choice of suture material
A. Chooses delayed absorbable suture over permanent suture Yes No
B. Chooses caliber of suture material between 3-0 and 0 Yes No
4. Reapproximates appropriate anatomic landmarks
A. Anal sphincter ends identified and reapproximated Yes No N/A
B. Suture placement at or beyond apex of defect Yes No
C. Hymenal ring reapproximated Yes No
D. Restoration of perineal body Yes No
E. Reapproximation of skin Yes No
5. Exposure
A. Able to expose defect for repair Yes No
B. If “No” in A, utilizes instruments or assistant as necessary to expose Yes No
6. Self evaluation of repair
A. Performs rectal exam after repair Yes No
B. Removes sponge from vagina Yes No
Total Time (<15 Minutes) Yes No Actual Time: _________
PROM: See workup in Gumby Guide.
- Sterile Spec > look for pooling, nitrazine, swab for ferning
- Get GC/CT swab and wet mount during spec exam
- GBS if not already done
- NO digital exam until talking to attending
- NST, AFI with ultrasound if unsure.